National HCH Council and

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HCH 101February 2003

• National HCH Council and
• HCH Clinicians Network

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Overview

• History of HCH
• Realities of homelessness in the U.S.
• HCH approach to care
• Service delivery and sponsorship arrangements
• Resources

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What is the history of the HCH program?

• Information adapted from McMurray-Avila,
• 2nd Edition (2001). Organizing health services
  for homeless people A practical guide

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How did the HCH program begin?

• 1985
• 19 demonstration projects were privately funded
  by the Robert Wood Johnson Foundation and the Pew
  Charitable Trusts with a focus on primary medical
  care and case management.

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The Federal Response

• 1988
• Title VI of the Stewart B. McKinney Homeless
  Assistance Act created the HCH program under
  Section 340 of the Public Health Service Act (109
  projects in 41 states were funded)
• The McKinney Act also provided funding for
  programs such as emergency food/shelter,
  transitional/ long-term housing, mental health
  services, education/job training

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The Federal Responsecontinued

• 1993
• The Bureau of Primary Health Care funded outreach
  programs for homeless children and their families
  in 10 HCH projects
• 1996
• Health Center Consolidation Act put HCH programs
  under Section 330(h) of the PHS Act (with
  Community and Migrant Health Centers)

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The Federal Responsecontinued

• As of February 2003
• There are now 154 homeless health care projects
  in all 50 states, plus the District of Columbia
  and Puerto Rico

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The Federal Responsecontinued

• 1993
• The Bureau of Primary Health Care funded outreach
  programs for homeless children and their families
  in 10 HCH projects
• 1996
• Health Center Consolidation Act put HCH programs
  under Section 330(h) of the PHS Act (with
  Community and Migrant Health Centers)

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154 HCH ProjectsFunded by DHHS/HRSA/BPHC
1985
2003
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What are the realities of homelessness in the
United States?
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HOUSINGAccording to the 2001 report from U.S.
Conference of Mayors 27-city survey

• Requests for assisted housing for
  families/individuals increased 86.
• Average wait is 16 months for public housing 20
  months for Sec. 8 Certifi-cates 22 months for
  Sec. 8 Vouchers.
• 19 of cities have stopped accepting applications
  for at least one assisted housing program due to
  excessive length of the waiting list.

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COST OF HOUSING

• The federal minimum wage has remained at 5.15
  since 1997
• The national median housing wage is 13.75 an
  hour
• There is no locale in the U.S. where housing is
  affordable at the minimum wage
• National Low Income Housing Coalition, (2001).

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HUNGER

• According to the 2001 report from U.S.
  Conference of Mayors 27-city survey
• Requests for emergency food assistance increased
  23.
• 14 of requests for emergency food assistance
  went unmet.
• 54 of people requesting emergency food
  assistance were members of families. 37 of the
  adults were employed.

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HOMELESSNESSAccording to the 2001 report from
U.S. Conference of Mayors 27-city survey

• Requests for emergency shelter increased 13.
  Requests by homeless families alone increased by
  22.
• An average of 37 of requests by homeless people
  overall and 52 of requests by homeless families
  alone are estimated to have gone unmet.
• People remain homeless an average of 6 months.

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HOMELESSNESS CONTD...

• More than 760,000 persons sleep on the streets or
  in shelters every night.
• In the late 1990s 2.3-3.5 million people were
  homeless at some time during an average year.
• Approximately 12 million adults in the U.S. have
  experienced homelessness during their lifetime.
• Urban Institute. What Will It Take to End
  Homelessness? (2001).

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Interagency Council on the Homeless, (1999).
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Who becomes homeless?

• 68 are male - 32 are female
• 66 are single adults
• 34 are families
• 84 of homeless families are headed by women
• Interagency Council on the Homeless, (1999).
• 1.35 million children per year
• 2 of children in the U.S.
• Urban Institute, (2000).

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AGE

• 0-12 56,387 11.0
• 13-19 34,694 6.8
• 20-44 279,954 55.0
• 45-64 128,388 25.0
• 65-84 11,942 2.2
• 85 741 0.001
• Total 512,106 100

2001 UDS Data
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Proportion of Adult and Child Clients by Race,
Ethnicity, and Language N512,111

• Asian/Pacific Islander - 2.1
• Black/African American - 37.4
• American Indian/Alaska Native - 1.4
• White - 33.9
• Hispanic or Latino - 20.2
• Unreported/Unknown - 5.0
• Clients best served by languages other than
  English - 15.0
• Uniform Data System, BPHC, 2001.

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Domestic Violence

• Of 777 homeless parents interviewed in ten U.S.
  Cities,
• 22 said they had left their last place of
  residence because of domestic violence.
• Homes for the Homeless, 1998

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Adverse Childhood Experiences Reported by
Homeless Clients

• History of foster care , group home or other
  institutional setting - 27
• History of childhood physical or sexual abuse -
  25
• History of childhood homelessness - 21
• Ran away from home - 33
• Forced to leave home - 22
• Interagency Council on the Homeless, (1999).

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HEALTH OF HOMELESS CHILDREN

• 29 otitis media
• 12.5 obesity
• 6.5 failure to thrive
• 10 iron deficiency anemia
• Only 40 of children 12-36 months were up to date
  with immunizations
• 40 asthma, 43 moderate to severe

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Psychological

• Childrens Depression Inventory
• Homeless Mean 10.3 vs 8.3 for Housed
• Childrens Manifest Anxiety Scale
• Score Indicating Further Evaluation Needed
  Homeless 31 vs 9 Housed
• Child Behavior Checklist
• Preschoolers Higher Scores on Anxiety,
  Depression and Acting-Out

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Childhood Development

• Delay in at least one Denver subscale
• 54 homeless vs. 16 housed
• Language and personal/social most significant
• 35 homeless vs. 85 housed in EIP
• 180,000 homeless preschoolers not in school

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Education

• Significant lower scores on WRAT-R and WISC-R
• 41 of homeless children failing or below average
  compared to 23 housed (maternal self-report)
• Increased school attendance because of McKinney
  Act provisions

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Street Youth

• 730,000 to 1.3 million nationally
• 25 Permanently homeless
• 50 Runaway secondary to abuse
• 75 Engaged in illegal activity
• 50 Involved with prostitution
• 50 Alcoholic, 80 Street Drugs, 35 IVDU

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Health of Homeless Adults

• Health conditions requiring regular,
  uninterrupted treatmentsuch as tuberculosis,
  HIV, addiction, and mental illnessare extremely
  difficult to manage without a stable residence.
• The Institute of Medicine has determined that
  individuals without a regular place to stay are
  far more likely than are those with stable
  housing to suffer from chronic medical conditions
  such as diabetes, cardiovascular disease, and
  asthma.

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What is the HCH approach to care?
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Obstacles to accessing mainstream health care
services

• Lack of financial resources or health insurance
• Lack of awareness of services
• Fragmented service system
• Fear or distrust of large institutions
• Finding shelter and food are higher priorities
  than health care
• Lack of transportation

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Obstacles to utilizing mainstream health care
services

• Provider attitudes
• Language and cultural barriers
• Scheduling difficulties
• Lack of comprehensive services
• Lack of documentation

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How do HCH projects overcome these obstacles?

• Comprehensive services
• Accessible services
• Staff sensitivity to homeless issues
• Philosophy of care

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Comprehensive Services

• Primary health care
• Outreach
• Substance abuse services
• Mental health services
• Case management
• Entitlement eligibility assistance
• Provision of or arrangement for emergency health
  services
• Referral for inpatient hospitalization

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Comprehensive Services

• Restorative dental services
• Vision services and eyeglasses
• Specialty care (podiatry, dermatology,
  cardiology, etc.)
• Complementary and alternative medicine therapies
• Housing assistance
• Employment/job training
• Respite/convalescent services

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Accessibility

• Take services where homeless people are located
• Arrange transportation to follow-up services or
  other agencies
• Provide services regardless of ability to pay
• Collaborate with other agencies to provide
  comprehensive services

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Outreach

• Contact with any individual who would otherwise
  be ignored (or unserved)in non-traditional
  settings for the purposes of improving their
  mental health, health, or social functioning or
  increasing their human service and resource
  utilization.
• Gary Morse, 1987

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Where does outreach take place?

• scheduled clinics in or near shelters, soup
  kitchens, drop-in centers or other homeless
  facilities
• street locations - vacant buildings, alleys,
  camps, parks, under bridges
• public facilities
• motels/SROs
• jails/detox programs
• rural areas

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What services are provided through outreach?

• Engagement Strategies
• Initiate conversation, offer food/beverage,
  offer blankets and clothing
• Information and Referral
• HCH services, other agency services, housing
  options
• Direct Services
• Medical care, mental health, substance use, case
  management services

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Staff Sensitivity to Homeless Issues

• Treat people with dignity and respect
• Sensitive to cultural and ethnic diversity
• Understand that homelessness is caused by a
  combination of structural barriers and personal
  vulnerabilities
• Use interdisciplinary teams to approach the
  complex needs of people experiencing homelessness

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Cross-Disciplinary Team Approaches

• Multidisciplinary
• Interdisciplinary
  Transdisciplinary
• Adapted from Patricia L. Rosenfield Potential of
  Transdisciplinary Research, Social Science
  Medicine. 3511,1992

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Multidisciplinary versus Interdisciplinary
Approaches

• Multidisciplinary
• Team members work parallel to each other to
  address common problems
• Results usually brought together at the end
• Doesnt ensure disciplines actually work together

• Interdisciplinary
• Team works jointly but still from
  discipline-specific perspectives
• New insights to address problems result from
  shared staff conferencing
• Improvement over the multidisciplinary approach

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Transdisciplinary Approach

• Teams work jointly to address common problems by
  using a shared conceptual framework drawing from
  discipline-specific theories, concepts and
  approaches
• Transcends separate disciplinary approaches
• Outside the box thinking
• Whole person orientation

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Philosophy of Care

• Ultimate goal of HCH Seek individual and
  systemic solutions to end homelessness
• Collaborate with others at local and national
  levels
• Involve homeless or formerly homeless people in
  HCH projects
• Avoid institutionalization of homelessness
• Put ourselves out of business

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What are the service delivery and sponsorship
arrangements of HCH projects?
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HCH Project Delivery Systems

• Free-standing HCH facilities such as clinics,
  respite units, drop-in centers, or residential
  units
• Hospital-based clinics
• Clinics and services in shelters or other
  homeless service sites
• Community health center clinics
• Mobile units
• Street outreach

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HCH Sponsorship Arrangements
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For more information and resources contact..
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National Organizations

• The National HCH Council and the HCH Clinicians
  Network www.nhchc.org
• HCH Information Resource Center
  www.prainc.com/hch
• National Coalition for the Homeless
  www.nationalhomeless.org
• National Alliance to End Homelessness
  www.endhomelessness.org

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Federal Agencies

• Bureau of Primary Health Care - HCH Branch
  www.bphc.hrsa.gov
• Center for Mental Health Services (CMHS) -
  Homeless Programs Branch www.mentalhealth.org
• Center for Substance Abuse Treatment (CSAT)
  www.samhsa.gov